SPEAKER 1: This course discusses suicide and contains headlines and images from news reports on suicide that can be disturbing. If you or someone you know is suicidal, please know help is available. Contact your physician, your local hospital emergency room, or a suicide prevention hotline or text line as shown on the screen. These helplines can provide free and confidential support 24/7. [MUSIC PLAYING] HOLLY C. WILCOX: Welcome. I'm Holly Wilcox. Along with Dr. Diana Clarke, I will be co-hosting this module providing an overview on suicide. First, we'll start with definitions of suicide. The Centers for Disease Control, the Webster's Dictionary, and the Institute of Medicine have provided some examples here. According to the Centers for Disease Control, suicide is death caused by injuring oneself with some intent to die. According to Webster's Dictionary, the act or an instance of taking one's own life voluntarily and intentionally. And the Institute of Medicine, death caused by self-directed injurious behavior with some intent to die as a result of the behavior. The common elements of these definitions are that the act must be self-inflicted, intentional, and the outcome must be death. However, one thing to consider is that suicide intent is not always clear. There's some level of ambiguity. And, oftentimes, the individuals classifying suicides, which could be community doctors coroners, medical examiners, do not have a lot of information in hand to make the determination. Just to give you some examples. A parachutist falls to the ground from 5,000 feet apparently dying from multiple injuries to the head and body. Is the death a suicide, homicide, or an accident? A man was found in a cemetery lit on fire. He died on the way to the hospital. The cause was carbon monoxide poisoning, and the mechanism was damage to his lungs from inhalation. Is this natural, suicide, homicide, or an accident? And there are many other examples like this. Sometimes a single driver in a motor vehicle is found with no other real information at the scene. And sometimes a body is found dead of an apparent opioid overdose. If there's a note at the scene, then this is good evidence that the individual did have suicide intent. But, oftentimes, the majority of times there is not a note when the individual is discovered. Is suicide a public health problem? Throughout this course, you will hear us refer to some statistics about the magnitude of the problem of suicide. However, it's important to note that each suicide leaves loved ones in the community devastated. Overall, suicide is underreported and stigmatized. Globally, more than 700,000 people die by suicide each year. But because of stigma, and because of overreporting, and because the rates fluctuate per year, sometimes you'll see 700,000, 800,000, 1 million suicides per year. So there is some fluctuation, and the numbers are impacted by underreporting and stigma. Globally, suicide is the 17th leading cause of death overall, although this fluctuates by year. In the United States, suicide is the second leading cause of death in young people 15 through 39 years of age. In the United States, each suicide costs approximately $3 million. And these costs are largely made up of medical costs and losses in productivity or work loss related costs. Given all of this, it seems clear that more investment is needed in prevention. A public health approach uses a set of coordinated and proactive strategies to address suicide prevention. So a public health approach would use surveillance, monitoring, analysis, an approach to outbreaks, disease prevention, strong communication, proactive emergency preparedness, recovery, environmental health, research, and health promotion. Often, suicide is communicated to the public in an overly simplistic way where there's one risk factor that's emphasized in causing the suicide death. However, suicide is complex and has a range of risk factors. There are population-level risk factors, such as changes in social structure, economic factors, and social factors. There are individual-level factors in the background, such as family history, early life stress and adversity, genetics, and epigenetic factors. There are other mediating traits and behaviors such as cognitive deficits, impaired problem solving and coping, high anxiety, impulsive aggression, chronic substance abuse. And then there are triggers that are close in time to the actual suicide. These can be life events such as relationship problems or divorce, job loss, arrest, hopelessness, depressed mood, current substance abuse, and risk taking behavior. Often, these factors can make the individual more disinhibited and more likely to act on their suicidal thoughts. In addition to personal and population-level factors, contextual factors are critically important. Examples of these are sensationalized media reporting of suicide, access to lethal means, and access to mental health care. Rates of suicidal behaviors vary across the context and can differ by differing proportions of risk and protective factors, reactions to suicidal behaviors, and patterns of help-seeking. There are cultural differences in social acceptability or taboo related to suicide. And this overlaps with religious, sociocultural, economic, and legal context within specific cultures. So it's very important to consider the cultural context when considering suicide risk. To this point, we've been really focusing on suicide deaths. However, the scope of the burden of suicide is even larger when considering suicidal thoughts and behaviors that are treated and the even larger occurrence of those thoughts and behaviors that are left untreated. Suicides are just the tip of the iceberg. A lack of agreed upon operational definitions of suicide-related terms has complicated our understanding of suicidal behaviors as well as suicide prevention efforts. So, here, I'll review some terms related to suicide. Suicidal ideation are thoughts of engaging in suicide-related behavior. Suicidal intent is evidence that the individual intended to kill themselves and understood the consequences of their actions. Suicide attempt is a non-fatal self-directed potentially injurious behavior with intent to die as a result of the behavior. Suicidal behaviors are acts and/or preparation toward making a suicide attempt or deaths by suicide. A suicidal plan are thoughts of killing oneself with details of the plan fully or partially worked out with some intent to carry it out. And suicide is death caused by self-directed injurious behavior with intent to die as a result of the behavior. So, here, you'll see that suicidal thoughts and behaviors exist along a continuum from thinking about ending one's life to ending one's life. Certain terms and phrases can further stigmatize suicide. And suicide is often spoken about in a pejorative way. We should say died of suicide or died by suicide rather than committed suicide because committed suicide implies some sort of criminality or criminalizes the act of suicide. One should say suicide attempt rather than unsuccessful attempt because unsuccessful implies some sort of failure. Rather than saying completed suicide, one should just use the term suicide. Rather than saying manipulative cry for help or suicidal gesture, one should just describe the actual behavior because this implies some sort of a judgment call related to the act. In working with suicidal families, rather than dealing with a suicidal crisis or dealing with a suicidal family is a more appropriate way to frame the issue. There is growing recognition that suicide may occur in clusters. A suicide cluster is a temporary increase in the frequency of suicides relative to the time preceding and after the cluster typically following the reporting of actual or fictional suicides. Evidence of contagion is strongest in newspaper reporting within the first couple of days to a week after publication, although it could be longer. The prominence and other characteristics of the story are influential. This could be, for example, whether the suicide is presented on the front page of a newspaper or whether there are graphic images of the decedent. Research consistently shows that aspects of news reporting may influence suicide clusters through imitation or contagion. And this is especially an issue among young people. Young people tend to be quick from thought to action. And the suicide clusters are about two to four times more common among young people aged 15 to 24 than other age groups. So just a word about content and trigger warnings. Think about the potential impact your story could have on people in distress or families who've just survived a suicide attempt or suicide death. Individuals from these groups and others might be upset by seeing your story or as we say triggered by seeing the story, even if your story is intended to be supportive or helpful. You can consider placing a warning at the beginning of your story explaining that it relates to suicide to let the readers decide on their own whether they want to read it. Of course, trigger warnings can't protect against all negative effects and can't take away any harms that a story could cause. A story with a trigger warning must still adhere to other responsible reporting guidelines in order to avoid causing suicide contagion. [MUSIC PLAYING] SPEAKER 1: This course discusses suicide and contains headlines and images from news reports on suicide that can be disturbing. If you or someone you know is suicidal, please know help is available. Contact your physician, your local hospital emergency room, or a suicide prevention hotline or text line as shown on the screen. These helplines can provide free and confidential support 24/7.